Rotator Cuff Anterior Cable Reconstruction With Long Head of Biceps Tendon Autograft.

Rotator cuff tears with anterior cable disruption show a more detrimental natural history than tears with an intact cable. Anterior cable reconstruction in the setting of such tears provides a potential avenue to improve tissue quality of the repaired construct and enhance repair longevity. Cadaveric studies investigating anterior cable reconstruction have shown biomechanical advantages. We present an arthroscopic surgical technique for rotator cuff anterior cable reconstruction using long head of the biceps tendon autograft in the setting of repairable large-to-massive rotator cuff tears with poor anterior cable tissue quality.

Natural Language Processing for the Identification of Surgical Site Infections in Orthopaedics.

BACKGROUND: The identification of surgical site infections for infection surveillance in hospitals depends on the manual abstraction of medical records and, for research purposes, depends mainly on the use of administrative or claims data. The objective of this study was to determine whether automating the abstraction process with natural language processing (NLP)-based models that analyze the free-text notes of the medical record can identify surgical site infections with predictive abilities that match the manual abstraction process and that surpass surgical site infection identification from administrative data. METHODS: We used surgical site infection surveillance data compiled by the infection prevention team to identify surgical site infections among patients undergoing orthopaedic surgical procedures at a tertiary care academic medical center from 2011 to 2017. We compiled a list of keywords suggestive of surgical site infections, and we used NLP to identify occurrences of these keywords and their grammatical variants in the free-text notes of the medical record. The key outcome was a binary indicator of whether a surgical site infection occurred. We estimated 7 incremental multivariable logistic regression models using a combination of administrative and NLP-derived variables. We split the analytic cohort into training (80%) and testing data sets (20%), and we used a tenfold cross-validation approach. The main analytic cohort included 172 surgical site infection cases and 200 controls that were repeatedly and randomly selected from a pool of 1,407 controls. RESULTS: For Model 1 (variables from administrative data only), the sensitivity was 68% and the positive predictive value was 70%; for Model 4 (with NLP 5-grams [distinct sequences of 5 contiguous words] from the medical record), the sensitivity was 97% and the positive predictive value was 97%; and for Model 7 (a combination of Models 1 and 4), the sensitivity was 97% and the positive predictive value was 97%. Thus, NLP-based models identified 97% of surgical site infections identified by manual abstraction with high precision and 43% more surgical site infections compared with models that used administrative data only. CONCLUSIONS: Models that used NLP keywords achieved predictive abilities that were comparable with the manual abstraction process and were superior to models that used administrative data only. NLP has the potential to automate and aid accurate surgical site infection identification and, thus, play an important role in their prevention. CLINICAL RELEVANCE: This study examines NLP's potential to automate the identification of surgical site infections. This automation can potentially aid the prevention and early identification of these surgical complications, thereby reducing their adverse clinical and economic impact.

Surgical approaches to intramedullary nailing of the tibia: Comparative analysis of knee pain and functional outcomes.

INTRODUCTION: Post-operative knee pain is common following intramedullary nailing of the tibia, regardless of surgical approach, though the exact source is controversial. Historically, the most common surgical approaches position the knee in hyperflexion, including patellar tendon splitting (PTS) and medial parapatellar (MPP). A novel technique, the semi-extended lateral parapatellar approach simplifies patient positioning, fracture reduction, fluoroscopic assessment, and implant insertion. It also avoids violation of the knee joint capsule. However, this approach has not yet been directly compared against the historical standards. We hypothesised that in a comparison of patient outcomes, the semi-extended approach would be associated with decreased knee pain and better function relative to knee hyperflexion approaches. METHODS: A trauma patient database from a Level I centre was queried for patients who underwent intramedullary nailing of the tibia between 2009 and 2013. Patients were surveyed for knee pain severity (NRS scale 1 to 10) and location, and completion of the Lysholm Knee Scale (LKS). Data was compared between the semi-extended lateral parapatellar, medial parapatellar, and tendon splitting groups regarding knee pain severity, location, total LKS, and individual knee function scores from the Lysholm questionnaire. Pre-hoc power analysis determined the necessary sample size (n=34). Post-hoc analysis utilised two-way ANOVA analysis with a significance threshold of p<0.05. RESULTS: Comparison of knee pain severity between the groups found no significant difference (p=0.69), with average ratings of: semi-extended (3.26), PTS (3.59), and MPP (3.63). Analysis found no significant differences in total LKS score (p=0.33), with average sums of: semi-extended (75.97), MPP (77.53), and PTS (81.68). Individual knee function scores from the LKS were similar between the groups, except for limping, with MPP being significantly worse (p=0.04). There was no significant difference in knee pain location (p=0.45). CONCLUSION: In this adequately-powered study, at minimum 1 year follow-up there were no significant differences between the 3 approaches in knee pain severity, location, or overall function. The three were significantly different in post-operative limping, with medial parapatellar having the lowest score. The semi-extended lateral parapatellar approach vastly simplifies many technical aspects of nailing compared to knee hyperflexion approaches, and does not violate the knee joint.

Cervical Scoliosis: Clinical and Radiographic Outcomes.

Study Design Retrospective study. Objective Cervical scoliosis is a rare condition that can arise from various etiologies. Few reports on the surgical management of cervical scoliosis exist. Our objective was to evaluate clinical and radiographic outcomes following surgical management of cervical scoliosis. Methods We evaluated our cervical spine surgical database for patients with cervical scoliosis (Cobb angle > 10 degrees) from 2005 to 2010. Demographic data including age, gender, diagnoses, and primary versus revision surgery was collected. Surgical data including procedure (anterior versus posterior), estimated blood loss (EBL), length of surgery, length of hospitalization, and complications was recorded. Preoperative and postoperative Cobb angle measurements and Neck Disability Index (NDI) scores were recorded. Results Cervical scoliosis was identified in 18 patients. We excluded 5, leaving 5 men and 8 women with an average age of 50.7 (median 52, range 25 to 65). The average follow-up was 40 months (median 36.5, range 5 to 87). An anterior-only approach was used in 6 cases (average 4 levels fused), 5 cases were posterior-only approach (average 8.7 levels fused), and 2 cases were combined anterior-posterior approach. The EBL was an average of 286 mL (median 150, range 50 to 900), the average surgical time was 266 minutes (median 239, range 136 to 508), and the average hospital stay was 2.7 days (median 2, range 1 to 7). Complications occurred in 7 patients, and 2 developed adjacent segment pathology. The average coronal Cobb angle preoperatively was 35.1 degrees (median 31, range 13 to 63) and corrected was 15.7 degrees (median 10.5, range 2 to 59) postoperatively (p < 0.005). The average NDI preoperatively was 24.9 (median 26, range 6 to 37) and was reduced to 17.8 (median 18, range 7 to 30) postoperatively (p < 0.02). Conclusion Surgical management of cervical scoliosis can result in deformity correction and improvement in patient outcomes. Higher rates of complications may be encountered.

Mycobacterium kansasii infection of the spine in a patient with sarcoidosis: a case report and literature review.

Mycobacterium kansasii is an acid-fast bacillus most commonly associated with pulmonary pathology. Infection of the spine is exceedingly rare, with just three reported cases, two of which were in human immunodeficiency virus and acquired immunodeficiency syndrome patients. This case report presents a case of vertebral osteomyelitis secondary to M. kansasii infection and reviews existing literature on this pathogen. The patient, a 37-year-old male with sarcoidosis, sustained a M. kansasii infection of the spine, resulting in vertebral osteomyelitis of L1 and L2 and discitis of the L1-L2 disc. This finding was confirmed by bone and intervertebral disc biopsy. Initially, the patient was thought to have a compression fracture of L2. However, the decision to perform a biopsy was made because of the patient's persistent febrile episodes and magnetic resonance imaging findings. The patient did not have any neurological deficits. He was successfully treated with antimicrobials, with no recurrent symptoms at 2-year follow-up. This case is the first reported case of a M. kansasii infection of the spine in a patient with sarcoidosis.

High-dose rhBMP-2 for adults: major and minor complications: a study of 502 spine cases.

BACKGROUND: Use of recombinant human bone morphogenetic protein-2 (rhBMP-2) has increased considerably since its introduction in 2002. The complications associated with high-dose rhBMP-2 (≥ 40 mg) are unknown. The purpose of our study was to determine outcomes and medical and surgical complications associated with high-dose rhBMP-2 at short-term and long-term follow-up evaluations. METHODS: Five hundred and two consecutive adult patients who had received high-dose rhBMP-2 as a part of spinal surgery from 2002 to 2009 at one institution were enrolled. Data were entered prospectively and studied and analyzed retrospectively. Surgical procedures in the thoracic and lumbar spine were included. Major and minor complications were documented intraoperatively, perioperatively, and at the latest follow-up examination. Complications potentially associated with rhBMP-2 use were evaluated for correlation with rhBMP-2 dose. Scoliosis Research Society (SRS) and Oswestry Disability Index (ODI) outcome measures were obtained before and after surgery. RESULTS: On average, 115 mg (range, 40 to 351 mg) of rhBMP-2 was used. The average age of the patients (410 women and ninety-two men) at the time of the index procedure was 52.4 years (range, eighteen to eighty years). There were 265 primary and 237 revision procedures, and 261 patients had interbody fusion. An average of 11.5 vertebrae were instrumented. The average duration of follow-up was forty-two months (range, fourteen to ninety-two months). The diagnoses included idiopathic scoliosis (41%), degenerative scoliosis (31%), fixed sagittal imbalance (18%), and other diagnoses (10%). The rate of intraoperative complications was 8.2%. The rate of perioperative major surgical complications was 11.6%. The rate of perioperative major medical complications was 11.6%. Minor medical complications occurred in 18.9% of the cases, and minor surgical complications occurred in 2.6%. Logistic regression analysis and Pearson correlation did not identify a significant correlation between rhBMP-2 dosage and radiculopathy (r = -0.006), seroma (r = -0.003), or cancer (r = -0.05). Significant improvements in the ODI score (from a mean of 41 points to a mean of 26 points; p < 0.001) and the SRS total score (from a mean of 3.0 points to a mean of 3.7 points; p < 0.001) were noted at the latest follow-up evaluation. CONCLUSIONS: This is the largest study of which we are aware that examines complications associated with high-dose rhBMP-2. Major surgical complications occurred in 11.6% of patients, and 11.6% experienced major medical complications. There was a cancer prevalence of 3.4%, but no correlation between increasing rhBMP-2 dosage and cancer, radiculopathy (seen in 1% of the patients), or seroma (seen in 0.6%) was found.

Arachnoiditis ossificans after revision adolescent idiopathic scoliosis surgery: a 22-year follow-up and review.

STUDY DESIGN: Case report. OBJECTIVE: To report the clinical and imaging findings of a patient with arachnoiditis ossificans (AO) 22 years after revision surgery for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: To our knowledge, there are no reports in the literature that describe AO developing after primary or revision surgery for AIS. Ararchnoiditis ossificans is a rare finding and we provide a review of its presentation and management. METHODS: We report the patient's history, physical examination, radiographical findings, and management in addition to providing a literature review. RESULTS: A 43 year-old-male who underwent revision surgery for AIS due to intradural migration of a laminar hook presented 22 years after surgery with subjective leg weakness. On physical examination, no weakness was elicited and radiographs demonstrated the instrumentation to be intact. Computed tomographic imaging was performed to assess for adjacent segment disease and diffuse ossification or AO of the thecal sac from L3 to S1 was noted. We recommended observation and nonoperative management because the patient's symptoms were relatively mild. CONCLUSION: To our knowledge, this is the first report of AO after surgical management of primary or revision AIS. A discussion on the management of AO and a literature review is presented.